Conjuctivitis Bacterial and Viral

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Compiled by: Dr. Iddi Ndyabawe
CONJUCTIVITIS, ACUTE BACTERIAL:
BASICS
DESCRIPTION
Acute conjunctivitis defines an inflammation of the conjunctiva, or the mucous membrane lining
the inner surface of the eyelids and the outer surface of the eyeball extending over the sclera.
Bacterial conjunctivitis is a very common condition.
EPIDEMIOLOGY
• Affects both children and adults of all ages
• No sex predominance
Incidence
• Acute conjunctivitis comprises about 1-2% of a primary care office visits.
• 1in 8 schoolchildren has an episode of acute infective conjunctivitis every year.
• There are approximately 6 million cases of conjunctivitis annually.
Prevalence
Bacteria are responsible for about 50-75% of all cases of acute conjunctivitis in young children.
RISK FACTORS
• Bacterial conjunctivitis occurs in otherwise healthy individuals.
• Risk factors include exposure to infected individuals, sinusitis, and immunodeficiency states.
Genetics
No genetic predisposition
GENERAL PREVENTION
Isolation of contagious patients for 24-48 h after initiation of antibiotic therapy.
PATHOPHYSIOLOGY
Inflammation of the conjunctiva, or the mucous membrane lining the inner surface of the eyelids,
and outer surface of the eyeball extending over the sclera

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ETIOLOGY
• Acute bacterial conjunctivitis:
-Staphylococcus aureus, Haemophilus influenzae,
Streptococcus pneumonia, Moraxella catarrhalis,
Staphylococcus epidermidis:
o H. influenzae and S. pneumonia are most common in children.
o S. aureus are most common in adults.
• Hyperacute bacterial conjunctivitis:
- Neisseria gonorrhea
• Chronic bacterial conjunctivitis:
-Chlamydia
COMMONLY ASSOCIATED CONDITIONS
• Otitis media:
-Frequently caused by H. influenza
~ DIAGNOSIS
There is considerable overlap in clinical signs and symptoms between viral and bacterial
conjunctivitis; clinical accuracy of 50%.
HISTORY
• More commonly associated with a bilateral unilateral red eye
• Eyelash matting
• Purulent yellow-green discharge
• Copious discharge associated with hyperacute bacterial conjunctivitis
• History of sexual activity associated with hyperacute and chronic conjunctivitis
• Exposure to a sick contact
PHYSICAL EXAM
• Palpebral papillary reaction
• Follicles develop with Chlamydia.
• Only 10% have associated a preauricular lymphadenopathy.
• Moraxella species, Chlamydia, and N. gonorrhea

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DIAGNOSTIC TESTS & INTERPRETATION
Lab
Initial lab tests
• Cell culture:
- •Gold Standard•; Not routinely performed
- Blood agar and chocolate agar
- Recommended for patients not responding to therapy, immune compromised patients. Contact
lens wearers in the setting of an outbreak, sexual active person with copious discharge
- Copious discharge suggests N. gonorrhea; requires culture on chocolate agar.
• Gram stain
- Copious discharge suggests N. gonorrhea; intracellular diplococci are suggestive.
• Polymerase chain reaction:
- Usually a send-out test; expensive
- Not FDA cleared
-Available for confirmation of Chlamydia and N. gonorrhea
Follow-up and special considerations
• Follow-up in 5-7 days
• 70% of patients with confirmed ocular chlamydia have a coexistent chlamydia genital
infection.
• Follow-up should be in 5-7 days. N. gonorrhea needs daily follow-up in the first 3 days.
- High risk of corneal ulceration with perforation
Diagnostic Procedures/Other
Immunoassay to rule out adenovirus
DIFFERENTIAL DIAGNOSIS
Acute viral conjunctivitis (HSV and adenovirus), allergic conjunctivitis. episcleritis/scleritis,
blepharitis, infectious or inflammatory keratitis, uveitis, and angle closure glaucoma.

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TREATMENT
MEDICATION
• Delayed therapy for 3 days is an option but forces isolation of contagious persons.
First line
• Acute bacterial conjunctivitis:
- Polytrim 1drop every 4-6 h for 7 days
- Fluoroquinolone 1 drop every 4-6 h for 7days i.e., moxilloxacin, gatifloxacin, levofloxacin,
besifloxacin
• Hyperacute bacteriaIconjunctivitis:
- Ceftriaxone 1 g intramuscularly (i.m.) in a single dose for presumed N. gonorrhea
- If corneal involvement exists, treat with ceftriaxone 1 g intravenously (i.v.) every 12-24h
-Topical fluoroquinolone q.i.d. without corneal involvement and q1-2h w1th corneal
Involvement
-In penicillin-allergic patients, consider an oral fluoroquinolone (e.g.• ciprofloxacin 500 mg p.o.•
for 5 days.
Second line
• Azithromycin I drop twice daily for 2days and then once daily for 3 additional days
• Older generation medications suffer from high rates of antibiotic resistance.
• Medications such as topical Tobramycin and Gentamycin may be associated with corneal
toxicity.
Other antibiotics such as Sulfa and Neomycin are associated with increased rates of allergic
reactions and should be avoided.
ADDITIONAL TREATMENT
General Measures
• Supportive care:
- Refrigerated preservative-free artificial tears
- Frequent hand washing
- Limit sharing of towels and linens
Issues for Referral
• Severe eye pain or headache, photophobia, decreased vision acuity, trauma or contact lens use
• Mid-dilated fixed pupil, hazy cornea
• No improvement after 7 days of antibiotic treatment

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• ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Follow-up is recommended for patients who develop reduced vision, pain, light sensitivity or if
symptoms persist beyond 7 days.
PATIENT EDUCATION
Educate patients on contagiousness.
PROGNOSIS
Self-limiting; most patients recover spontaneously.
COMPLICATIONS
Complications are rare.
CLINICAL PEARLS
• Consider more serious eye disease if there is a unilateral red eye, reduced visual acuity, severe
pain, significant photophobia, contact lens wear, or recent
ocular surgery or trauma. Purulent discharge is associated with bacterial conjunctivitis.
• Negative cultures are associated with:
1) age >6 years,
2) presentation during April through November
3) watery or no discharge, and
4) no glued eye in the morning.
• Antibiotic treatment of bacterial conjunctivitis reduces the duration of clinical illness by
0.5-1.5 days and hastens microbiological cure.

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CONJUNCTIVITIS, ACUTE VIRAL
~ BASICS
DESCRIPTION
Acute conjunctivitis defines an inflammation of the conjunctiva, or the mucous membrane lining
the inner surface of the eyelids and outer surface of the eyeball extending over the sclera. Viral
conjunctivitis is a very common condition and adenovirus is the most frequent cause of
conjunctivitis worldwide.
EPIDEMIOLOGY
• Affects both children and adults of all ages
• No sex predominance
Incidence
• Acute conjunctivitis comprises about 1-2% of a primary care office visits.
• There are approximately 6 million cases of conjunctivitis annually.
Prevalence
20-70% of acute conjunctivitis is viral.
RISK FACTORS
• < 5% of the US population shows natural immunity against adenovirus.
• Adenovirus can live on inanimate surfaces for 5weeks:
- Overcrowding or close quarters
- Urban setting
- Exposure to a sick contact
Genetics
No genetic predisposition
GENERAL PREVENTION
• Isolation of contagious patients:
- Adenoviral conjunctivitis shows close contact and intra-familial spread of 20-40%.
PATHOPHYSIOLOGY
Inflammation of the conjunctiva, or the mucous membrane lining the inner surface of the eyelids,
and outer surface of the eyeball extending over the sclera

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ETIOLOGY
• Viral conjunctivitis represents 20-70% of all acute conjunctivitis.
-Adenovirus accounts for 65-90% of viral conjunctivitis.
o Presents as 1 of 4 clinical conditions:
-Epidemic keratoconjunctivitis (EKC),
-acute hemorrhagic conjunctivitis (AHC),
-pharyngoconjunctival fever (PCF), and
-nonspecific follicular conjunctivitis (NFC)
-Herpes simplex virus (HSV) accounts for 1.3-21% of viral conjunctivitis.
o These cases occur without associated skin vesicles or keratitis.
- Other less common viruses include Molluscum contagiosum, varicella-zoster virus (VN),
coxsackie virus, enterovirus echovirus.
Epstein-Barr virus, human immunodeficiency virus and cytomegalovirus.
COMMONLY ASSOCIATED CONDITIONS
• Adenovirus may be associated with viral prodrome followed by adenopathy, fever, pharyngitis,
or an upper respiratory tract infection.
• HSV and VZV may be associated with a vesicular skin rash and/or keratitis.
~ DIAGNOSIS
HISTORY
• More commonly associated with a bilateral red eye
• Starts in one eye and then moves to the other several days later
• Watery to mucoid discharge
• Recent upper respiratory symptoms
• Exposure to a sick contact
PHYSICAL EXAM
• Injection
• Palpebral follicular reaction
• Microhemorrhages
• Pseudomembranes
• Superficial punctuate keratopathy
• Subepithelial infiltrates:
- Only occurs after 7-10 days

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• Pre-auricular lymphadenopathy:
- Only present in 30-50%
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Point of care immunoassay for adenovirus with a sensitivity of 88-89% and a specificity of 91-
94%:
- 10min in office test
- Detects viable and nonviable virus fragments
-Antigen levels diminish after 7days
• Viral cell culture:
- May take 3-21 days to grow
- •Gold Standard•
- Only detects live virus
• Polymerase chain reaction:
- Usually a send-out test; expensive
- Not FDA cleared
- Detects both viable and nonviable viral fragments
Diagnostic Procedures/Other
Serological tests for HSV lgM and lgG
DIFFERENTIAL DIAGNOSIS
-Acute bacterial conjunctivitis, allergic conjunctivitis
-Episcleritis/scleritis
-Blepharitis
-dry eyes
-infectious or inflammatory keratitis
-uveitis
-angle closure glaucoma.

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TREATMENT
MEDICATION
First line
o Adenoviral conjunctivitis has no FDA approved antiviral agents.
- Refrigerated preservative-free artificial tears every 2h
-Topical antihistamines twice daily for significant itching
-Topical ganciclovir gel:
o Small, randomized, controlled, masked series of 18 patients showed decreased duration of
disease.
o HSV should be treated with topical antiviral:
-Topical ganciclovir gel 0.15% 5times per day
- Trifluridine 1% (Viroptic) drops 5 times per day
Second line
o Topical steroids may be considered in the presence of pseudomembranes or subepithelial
infiltrates.
- Steroids should be avoided except in severe disease because of associated increased viral
replication and prolonged infectivity.
o Consider loteprednol twice to 4 times daily or a steroid ointment such as fluorometholone 0.1%
or dexamethasone/tobramycin 4 times daily.
ADDITIONAL TREATMENT
General Measures
o Supportive care:
- Refrigerated preservative-free artificial tears
- Frequent hand washing
-Limit sharing of towels and linens
- Home disinfection
Issues for Referral
o After 7-10 days patients may develop subepithelial infiltrates (corneal deposits).
- Manifest as reduced vision or photosensitivity
Additional Therapies
Analytical laboratory studies and anecdotal support for povidone iodine therapy exist.
• ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Follow-up is recommended for patients who develop reduced vision, light sensitivity, or if
symptoms persist beyond 10 days.

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PATIENT EDUCATION
• Educate patients on extreme contagiousness.
o Educate patients on the ineffectiveness of topical antibiotics.
PROGNOSIS
o Most patients recover spontaneously.
o 20-50% at patients with EICC develop SEIs or chronic dry eyes.
COMPLICATIONS
o Corneal subepithelial infiltrates (inflammatory deposits)
o Chronic dry eye
o Conjunctival scarring
• Chronic epiphora (tearing)
CLINICAL PEARLS
o A 50% clinical accuracy was found compared to laboratory diagnosis.
• HSV may present with EKC that is indistinguishable from adenovirus